NCLEX Gastrointestinal Disorders
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Question 1 of 5.
The client recovering from acute pancreatitis who has been NPO asks the nurse, “When can I start eating again?†Which response by the nurse is most accurate?
A. “As soon as you start to feel hungry you can begin eating.â€
B. “When I hear that your bowel sounds are active and you are passing flatus.â€
C. “When your pain is controlled and your serum lipase level has decreased.â€
D. “You will be NPO for at least more 2 weeks; oral intake stimulates the pancreas.â€
Explanation: A. Regaining appetite is a positive sign, but it must be accompanied by a decrease in pain before the client is allowed to take food orally. B. Intestinal peristalsis may be slowed due to inflammation associated with acute pancreatitis, but the return of bowel sounds and flatus is not used to determine when to begin oral intake. C. This response is correct. Once pain is controlled and the serum enzyme levels begin to decrease, the client can begin oral intake. These are signs that the pancreas is healing. D. There is no specific time limit for being NPO.
Question 2 of 5.
The client who had abdominal surgery tells the nurse, 'I felt something give way in my stomach.' Which intervention should the nurse implement first?
A. Notify the surgeon immediately.
B. Instruct the client to splint the incision.
C. Assess the abdominal wound incision.
D. Administer pain medication intravenously.
Explanation: Assessing the wound first determines if dehiscence or evisceration has occurred, guiding further action. Notification, splinting, or pain medication follow based on findings.
Question 3 of 5.
The client who had an abdominal surgery has a Jackson Pratt (JP) drainage tube. Which assessment data warrant immediate intervention by the nurse?
A. The bulb is round and has 40 mL of fluid.
B. The drainage tube is taped to the dressing.
C. The JP insertion site is pink and has no drainage.
D. The JP bulb has suction and is sunken in.
Explanation: A round JP bulb with 40 mL of fluid indicates loss of suction, risking fluid accumulation and infection, requiring immediate intervention. Taping, pink site, and suction are normal.
Question 4 of 5.
The 84-year-old client comes to the clinic complaining of right lower abdominal pain. Which question is most appropriate for the nurse to ask the client?
A. When was your last bowel movement?
B. Did you have a high-fat meal last night?
C. Can you describe the type of pain?
D. Have you been experiencing any gas?
Explanation: Describing the type of pain (e.g., sharp, dull, colicky) helps differentiate causes like appendicitis, diverticulitis, or obstruction, guiding diagnosis. Bowel movements, diet, and gas are secondary.
Question 5 of 5.
The female client diagnosed with anorexia nervosa is admitted to the hospital. The client is 67 inches tall and weighs 40 kg. Which client problem has the highest priority?
A. Altered nutrition.
B. Low self-esteem.
C. Disturbed body image.
D. Altered sexuality.
Explanation: Altered nutrition is the priority due to severe underweight (BMI ~13.2), risking organ failure and death. Self-esteem, body image, and sexuality are psychosocial and secondary.
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